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Bulgaria

Health care expenditure (SHA 2011) (hlth_sha11)

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Compiling agency: National Statistical Institute of Bulgaria

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Health care expenditure quantifies the economic resources dedicated to health functions, excluding capital investment. Healthcare expenditure concerns itself primarily with healthcare goods and services that are consumed by resident units, irrespective of where that consumption takes place (it may be in the rest of the world) or who is paying for it. As such, exports of healthcare goods and services (to non-resident units) are excluded, whereas imports of healthcare goods and services for final use are included.
Health care expenditure data provide information on expenditure in the functionally defined area of health distinct by provider category (e.g. hospitals, general practitioners), function category (e.g. services of curative care, rehabilitative care, clinical laboratory, patient transport, prescribed medicines) and financing scheme (e.g. social security, private insurance company, household). For the collection of the data on health care expenditure the System of Health Accounts (SHA) and its related set of International Classification for the Health Accounts (ICHA) is used. SHA sets out an integrated system of comprehensive and internationally comparable accounts and provides a uniform framework of basic accounting rules and a set of standard tables for reporting health expenditure data. The System of Health Accounts - SHA 2011  is a statistical reference manual giving a comprehensive description of the financial flows in health care.

It provides a set of revised classifications of health care functions, providers of health care goods and services and financing schemes. The SHA is currently used as a basis for a joint data collection by OECD, Eurostat and WHO on health care expenditure. The manual sets out in more detail the boundaries, the definitions and the concepts of health accounting – responding to health care systems around the globe with very different organisational and financing arrangements.

Accounting period: Health expenditure and financing data pertain to the calendar year (1 January to 31 December).

16 May 2024

SHA concept is the consumption of health care goods and services.

Health care statistics describe the process of providing and financing health care in countries by referring to health care goods and services, its providers and financing. For the collection of the data on health care expenditure the System of Health Accounts (SHA) and its related set of International Classification for the Health Accounts (ICHA) is used. SHA is a tri-axial system in which the financing, provision and consumption dimensions are covered by the ICHA (International Classification for Health Accounts): Health Care Functions (HC), Health Care Providers (HP), Health Care Financing Schemes (HF).

Data are presented in 3 summary (one-dimensional) tables and 3 cross-classification tables (2-dimensional tables).

Summary tables provide data on:

  • Current expenditure by provider (ICHA-HP);
  • Current expenditure by function (ICHA-HC);
  • Current expenditure by financing scheme (ICHA-HF).

Cross-classification tables refer to:

  • HC x HP: Health care expenditure by function and provider: data on which type of health care goods and services are supplied by which health care provider;
  • HC x HF: Health care expenditure by function and by financing scheme: data on how are the different types of services and goods financed;
  • HP x HF: Health care expenditure by provider and by financing scheme: data on from which health care provider and under which particular financing scheme are the services and goods purchased.

The classifications and definitions presented in the SHA 2011 manual are to be followed. Additional guidelines and material useful for compilers are also available at this address.

Commission Regulation (EU) 2021/1901, and Commission Regulation (EU) 2015/359 previously in force,  concern the collection of data on "current expenditure on healthcare" which is defined as the "final consumption expenditure of resident units on health care goods and services".

There is a very close relationship between the concept of "final consumption expenditure" as defined in the System of Health Accounts (SHA) and in National Account and, as a consequence, also between the underlying economic transactions as recorded in the two accounting frameworks.

In National Accounts there are two types of statistical units: institutional units and local kind-of-activity units (KAU). A local KAU groups all the parts of an institutional unit in its capacity as producer which are located in a single site. A local KAU belongs to one and only one institutional unit.

SHA uses the same two types of units for data compilation.

Local KAUs operating as providers of healthcare goods and services to resident units are statistical units in SHA.

Also transactions by institutional units are recorded in SHA, in which framework institutional units are also referred to as "financing agents". More precisely, SHA financing agents are institutional units that manage one or more financing schemes. The transactions are executed by the financing agents, according to the rules of the financing schemes.

Financing agents serve as key statistical units in producing national health accounts. While financing schemes are the key units for analysing how the consumption of health care goods and services is financed, the data concerning the relevant transactions are collected either from the financing agents that operate the different financing schemes or from the providers.

The concept of "healthcare financing schemes" in SHA is an application and extension of the concept of "social protection schemes" defined by the European System of Social PROtection Statistics (ESSPROS):  "a distinct body of rules, supported by one or more institutional units, governing the provision of social protection benefits and their financing ...". The social protection scheme is the statistical unit in ESSPROS. It is an analytical unit that allows describing the complete structure of the social protection financing system:  expenditure and receipts.

According to SHA Manual 2011, "the key concepts for describing the structure of the health care financing system are based on measuring: (a) the expenditure of health care financing schemes, under which goods and services are purchased directly from health care providers, on the one hand, and (b) the types of revenues of health care financing schemes, on the other hand.  

Commission Regulation (EU) 2021/1901  and (prior Commission Regulation (EU) 2015/359) limits its scope to the collection of data on the expenditure of health care financing schemes.

SHA focuses on the consumption of health care goods and services by the resident population irrespective of where this takes place. This implies the inclusion of imports (from non-resident providers) and the exclusion of exports (health care goods and services provided to non-residents).

The data aims at providing a complete overview of expenditure on health care goods and services consumption of services and goods by the resident population on the national territory of a country.

Health care expenditure data are annual data, corresponding to the calendar year.

This quality report covers the following reference years: 2017 - 2021.

The sources to compile the data on health care expenditure are mainly administrative and register-based data, only a small percentage of the figures come from surveys or other means. Accordingly, for the health care expenditure data collection, accuracy deals with problems of coverage as the main possible source of errors.

Current expenditure data are presented according to following units:

  • expenditure amount in millions of euro;
  • expenditure amount in millions of national currency;
  • expenditure amount in millions of PPS;
  • percentage of GDP;
  • amount in euro per capita;
  • amount in national currency per capita;
  • amount in PPS per capita;
  • percentage of current health expenditure (CHE).

SHA data is compiled both by a bottom-up approach as well as by a top-down approach, depending on the data source. Compilation is done by financing schemes and by different health care functions/task areas. The results of the several calculations are then aggregated.

To gain the differentiation between the different SHA-dimensions (especially HC and HP) quotas and pro-rating and utilisation keys are applied on some spending items. For some spending items it is necessary to extra-/intrapolate data as there is no up-to-date data available or data is missing for certain years. For some other spending items, estimation methods have to be applied.

Several methods are normally used for estimations:

  • Balancing item/Residual method: For example, if data are available from the financing side, which permit accurate estimation of the flows to a provider or function, then an acceptable estimation method is to subtract these expenditure flows from the total revenues, and derive the expenditure flows from the unmeasured financing scheme as a residual.
  • Pro-rating/Utilisation key: Typically in the absence of direct spending data, a utilisation key linked to the proportion of resources used can be constructed in order to distribute e.g. aggregate provider spending across functions. For every key a fraction of total utilisation within the cost-unit is assigned: fractions in the key must add up to 100% of all care delivered by the cost-unit. Examples of utilisation keys are admissions, bed-days, contacts, staffing, etc.
  • Interpolation/Extrapolation: In the absence of data for the period in question, missing values can be estimated using known data points.
  • Or other.

Estimation methods

SHA variable(s) Main method Brief description of methodology
HF.2.1 (financing HC.1.1, HC.1.3.1, HC.1.3.2, HC.1.4, and HC.0  provided by HP.1.1, HP.3.1, HP.3.2, HP.3.4, HP.8.2, and HP0) Balancing item/Residual method Annual records on accountancy and statistical reports of Private health insurance funds are taken into account. Additional information on paid health insurance premiums is collected from the PHIF. The information is reclassified by functions and providers based on reported 'medical packages' (as utilization key).
HF3xHP.3.1/3.2 and HC1.3.1 Interpolation/Extrapolation Business statistical surveys (annual records on accountancy and statistical reports) conducted by NSI are the basic data source. First, sample of enterprises is made using NACE Rev. 2 codes. Additional tables where the data are aggregated by providers, classified by SHA classification, are made for the purposes of SHA. Then data are proceeded case by case in order to classify the revenue from population data in accordance to functions. An exhaustive survey 'In-patient, out-patient and other health care establishments' carried out by NSI was used in order to verify the coverage of the business statistical surveys for the appropriate NACE codes. The National Health Insurance Fund data on number of individual and group practices for primary and specialised medical end dental care was also used. As a result, outpatient health care establishments undercoverage is found. The HP.3.1/3.2 providers' revenue from population is estimated. The National Accounts estimations on household’s individual consumption of health services are taken into account as well.     
HF3xHP.3.1/3.4/5.1/6 and HC6.2 Pro-rating/Utilisation key National Center for Public Health and analyses at the Ministry of Health satistical data on immunizations and reimmunizations carried out in medical and health care facilities is the basic data source conserning the number of voluntary vaccinations and the distribution by establishments (provider side). Administrative data are used in respect to the price of vaccines.  
HF3xHC.5 splitting HPHP51/HP52/HP59 and HP82 Pro-rating/Utilisation key Business statistical surveys (annual records on accountancy and statistical reports and survey on domestic trade) conducted by NSI are the basic data source. Data is compiled on the basis of data obtained through annual accounting and statistical reports, regularly collected by the NSI. Value data are shown at prices of the corresponding year. The retail sale indicator includes the value of goods sold directly at prices of realization (including VAT and excises) to the population, institutions and departments for household needs. Retail sales by group of goods are used (according to the COICOP). Estimations are done based on NACE code of the enterprises, analizys of their economical activity and COICOP codes. HP5.9 - electronic or mail-order shopping is included (NACE 47.91); HP8.2 - over-the counter medicine sales in supermarkets are included (NACE 47.1, 47.2, 47.78). Except mail-order shopping and over-the counter medicine sales in supermarkets all other household’s expenditures can not be disaggregated to prescribed and non-prescribed.HBS data are used for validation.
Since 2020 - Register of persons performing activities for the provision of medical devices and aids, devices and equipment for people with disabilities is used in order to verify the HC5.2 expenditure payed by HF3.
Since 2021 -National Center for Public Health and Analyzes at the Ministry of Health exhaustive annual survey on the immunizations and reimmunizations carried out in the medical and health facilities is used in order to verify and balanced the HC5.1 expenditure payed by HF3.  

Administrative and statistical data sources

Source name Brief description of source
(e.g. coverage, reference year, etc)		 Type of data source Primary SHA variable(s) using this data source Time period covered by this data source Timeliness
(Number of months after the end of the accounting period)		 Frequency
(e.g monthly, quarterly, annual, irregular)		 Processing
(e.g. brief description of any adjustments, correction or distribution applied to the original data sources)
Ministry of Finance   The main source of financial information for public sector is the Consolidated State Budget, with the budgetary classifications. The consolidated budget covers all health activities financed by the state budget; budgets of ministries and other institutions; National health insurance fund, etc. The consolidated state budget on function Health gives the information for the total amount of funding on that function reported from the main financial agents.
As regards COVID-19 related costs, additional reports are used as data source - Report on measures to prevent the spread of COVID-19 and its treatment, business support measures and social measures (other ministries data except the Ministry of Health);
Report on expenditures and sources of their funding in connecton to the measures to prevent the spread of COVID-19 - concerning expenditure payed by munisipalities (only respective mesures are included.
Decree of the Council of Ministers on the activities delegated by the state and financed by the munisipality budgets - as regard the expenditure on the service "Assistant support" .		 Public administrative records HF.1.1 (financing HC.1.1, HC.1.3, HC.2.1, HC.3.4, HC5.1, HC.6.1, and HC.6.4 provided by HP.1.1, HP.6, HP.8.1 and HP.8.2) 2003 - 2021 9 months Annual Unified budget classification of revenues, expenditures by economic type, transfers, financing, functional classification of expenditures by functions, groups and activities is used in order expenditures to be reclasified. The health care boundary is defined (expenditure on creches are excluded). Coding of expenditure data according to the HC/HP, calculation of aggregates for the inclusion into the SHA tables. 
National Health Insurance Fund Report on NHIF budget execution; In addition detailed administrative information on the expenses of the NHIF according to the SHA tables is provided.  Financial reports HF.1.2 (financing HC.1.1, HC.1.2, HC.1.3, HC.2.1, HC.2.3, HC.3.1, HC.4.1, HC.4.2, HC.5, HC.6.2, HC.6.3, HC.6.4, HC.7.2 and HC0 provided by HP.1, HP.2.1, HP.3.1, HP.3.2, HP.3.4, HP.4.2, HP.5.1, HP.5, HP.7.2, and HP.9) 2003 - 2021 9 months Annual Data are provided by the NHIF using predefined tables according to the SHA methodology. No additional adjusments and corrections are made by the BNSI.
Ministry of Health Detailed administrative information on the expenses of the MH according to the SHA tables is provided. Financial reports HF.1.1 (financing HC.1.1, HC.1.3, HC.2.1, HC.3.1, HC.4, HC.6.1, HC.5.1, HC.6.2, HC.6.3, HC.6.4, HC.6.5 and HC.7.1 provided by HP.1, HP.2.9, HP.4, HP.6, HP.7.1 and HP.8.2) 2003 - 2021 9 months Annual Data are provided by the MoH using predefined tables according to the SHA methodology. No additional adjusments and corrections are made by the BNSI.
Accountancy and statistical reports  Annual records on accountancy and statistical reports, collected by NSI:
1/ Health establishments applying double-entry accounting – “Annual report of non-trade enterprises” and particularly “Report for revenue and expenditures” and statistical “Report on revenue and expenditures by types”
2/ Health establishments applying single-entry accounting – “Annual report for enterprises that do not prepare balance”
These reports are compulsory for all types’ private (and state) enterprises (incl. health establishments, which provide commercial health services). Data on revenue from the overall activity of enterprises (applying single or double-entry accounting) is reported by types of revenue based on Law on Accountancy.		 Surveys/censuses NACE code that are covered: 86, 87, and 32.50

Concerning HP5 and HP8.2 - NACE codes that are covered: 21, 26, 46, 47.1, 47.2, 47.73, 47.74, 47.78, 47.91. Information on the Wholesale and Retail sales by commodity groups, content of which is in accordance with the Classification of Individual Consumption by Purpose (COICOP) is used.

HF.3.1 ((financing HC.1.1, HC.1.3.1, HC.1.3.2, HC.1.4, HC.2.1, HC.3.1, HC.4.1, HC.4.2, HC.5,HC.6.1,  provided by HP.1, HP.2.1, HP.3.1, HP.3.2, HP.3.4, HP.3.5, HP.4.2, HP.5, HP.6 and HP.8.2)                            
HF.2.3 financing HC.6.4 provided by HP.8.2
HF.2.1 (financing HC.1.1, HC.1.3.1, HC.1.3.2, HC.1.4 and HC.0  provided by HP.1.1, HP.3.1, HP.3.2, HP.3.4, HP.8.1, and HP0)		 2003 - 2021 11 months Annual Concerning HF3.1:
1. Additional tables where the data are aggregated by providers, classified by SHA classification, are made for the purposes of SHA.
2. Data are proceeded case by case in order to classify the revenue from population data in accordance to functions. In this way we hope that both the funding and provider sides are considered.
3. Generally the National Accounts estimations on household’s individual consumption of health services as well as HBS results are taken into account and a cross-validation between results obtained from NSI annual business statistical surveys, HBS and national accounts estimates is done.
4. National Center for Public Health and Analyses at the Ministry of Health statistical data on the immunizations and reimmunizations carried out in medical and health care facilities are used to estimate the expenditures of households for voluntary vaccinations.
The provider’s revenue from population is considered as appropriate source for estimation of out-of-pocket expenditure of households.
In respect to the HC.5 - Value data are shown at prices of the corresponding year. The retail sale indicator includes the value of goods sold directly at prices of realization (including VAT and excises) to the population, institutions and departments for household needs.

Concerning HF2.1:
Annual records on accountancy and statistical reports of Private health inshurance funds are taken into account.
Till 2012 the basic source of information was the Annual report of the Financial Supervision Commission. In the middle of the 2013 the national legislation was changed. The information on paid health insurance premiums was available by the mid-year. This necessitated to collect the information directly from the Private health inshurance funds. 
Since 2016 a new statistical report is included. 2015 and 2016 data were collected simultaneously. The information on paid health insurance premiums is reclassified by functions and providers based on reported 'medical packages' and experts estimation.
National Social Security Fund Report on NSSF budget execution Public administrative records Expenditure for rehabilitation (HC2.1) done by National Social Security Institute (HF1.2/1.3) and paid directly to the providers (HP1.3) 2003 - 2021 9 months Annual Public available report is used. No additional adjusments and corrections are made by the BNSI.
National Accounts  The National Accounts' estimations on individual consumption expenditures by NPISHs of health. Other HF2.3 (Expenditure done by NPISHs (HC.0 ) and paid to the providers (HP8.1)) 2003 - 2021 9 months Annual No additional adjusments and corrections are made by the SHA team.
Social Assistance Agency at the Ministry of labor and social policy Detailed administrative information on the expenses of the SAA according to the SHA tables. Financial reports Expenditure on rehabilitation of people with disabilities done by SAA (HF1.1) and paid to the beneficiaries. According to the national legislation rehabilitation is provided by Specialised hospitals for rehabilitation only (HP1.3). The expenditure are done by the persons and reimburced by the SAA based on the document for the expenses (invoice).
Expenditure on hospital aid for diagnosis and treatment (HC11) in the hospitals (HP1.1) of Bulgarian citizens who do not have income and / or personal property to ensure their personal participation in the health insurance process. According to amendments in the national legislation, from 2013 the expenditure are paid to the establishments by SAA (HF1.1) through a transfer to the NHIF.
Expenditure on medications (HC51) based on doctor's prescriptions from a special list, approved by the Minister of Health as well as on dental care for all activities outside the scope of the basic package of healthcare activities, guaranteed by the National Health Insurance Fund (HC132) to the War Veterans, War Invalids and Victims. According to amendments in the national legislation, from 2013 the expenditures on medications are paid to the pharmacies that have a contract with NHIF (HP51) by the SAA (HF1.1) through a transfer to the NHIF. The costs on dental care are paid by the SAA.
Expenditure on providing personal assistance for people with disability in accordance with the Personal Assistance Act payed by SAA (HF1.1хHC3.4).
Permanently disabled people mean persons with a permanent physical, mental, intellectual or sensory deficit which, when in interaction with the environment, could impede their full and effective participation in social life, whereby such persons' expert medical assessment has ascertained a type and degree of disability or degree of permanently reduced working capacity 50 and over 50 percent.		 2013 - 2021 7 months Annual Detaled information (incl. metadata) on preparation of ESSPROS tables is provided by SAA. In addition, the Report on MLSP and SAA budget execution is used (public available). Coding of expenditure data according to the HC/HP, calculation of aggregates for the inclusion into the SHA tables. 

Annual.

Member States were required to transmit their data to Eurostat in compliance with the Commission Regulation (EU) 2015/359 transmission deadlines, until reference year 2020. As of reference year 2021, data are transmitted pursuant to Commission Regulation (EU) 2021/1901.
Data and reference metadata for the reference year T should be transmitted to Eurostat by 30 April T+2.

Not applicable.

Year Items affected by the break Explanations
2009 - 2011 Data are provided on 1st digit level  Insuficient information at a more disaggregated level. 
2013 HF1.1, HF3
HC1.1, HC1.3.2, HC5
HP1.1, HP3.2, HP5		 New data source is identified - Social Assistance Agency at the Ministry of labor and social policy. According to amendments in the national legislation, from 2013 the expenditure on hospital aid, dental care and medication to specific groups of population are paid by the SAA (HF1.1) through a transfer to the NHIF.
Additional analizys on the households' expenditure on medical goods were done by using detaled data from the Information System Business Statistics and HBS sample survey.  
2017 HC41 and HC42 financed by HF3 Till 2016 the expenditure for ancillary services (HC4) paid by households (HF3) could not be disaggregated for Laboratory and Imaging services. All expenditures were reported in HC41. Since 2017 these expenditures has been reported separately.
2017 HF1.2.1 Till 2016 all expenditure payed by HF1 are reported on a cash basis. Since 2017, “accrual” principle for the National Health Insurance Fund data is applied.  
2020 HC6.2xHP11 payed by HF1.1 Expenditure on immunisation programmes for new-borns (till 2019 reported under HC11xHP11). 
2021 HC6.2xHP.3.1/3.4/5.1/6 payed by HF3 Expenditure on voluntary (non-programmed) vaccinations. Till 2020 HF3 on those that can be purchased at pharmacies are part of HC5.1. Some of the voluntary vaccines are placed only in certain vaccination offices, which are authorized to issue a certificate - reported under HC1 and different HP. 

Other comperability issues

HP5xHC5 dissagregation and HP8.2xHC5 - Since 2011 expenditure are estimated in more detail. Business statistical surveys (annual records on accountancy and statistical reports and survey on domestic trade) conducted by NSI are the main data source. Data is compiled on the basis of data obtained through annual accounting and statistical reports, regularly collected by the NSI. Retale sales by group of goods are used. Estimations are done based on NACE code of the enterprices. HP5.9 - electronic or mail-order shopping is included (NACE 47.91); HP8.2 - over-the counter medicine sales in supermarkets are included (NACE 47.1, 47.2, 47.78). Except mail-order shopping and over-the counter medicine sales in supermarkets all other household’s expenditures can not be disaggregated to prescribed and non-prescribed.

2019 - With amendments of the national legislation, some of the activities prior financed by the budget of the Ministry of Health, since 2019 have been financed by the NHIF: activities of Fund for Treatment of Children, some specific activities for treatment and care of new-borns, activities for renal replacement therapy, some medical devices used in hospital treatment etc. This is the reason for some variation across financing schemes HF11 and HF121.

2020 - EU funds in the appropriate category under HF1.1 are covered. With an amendments, approved by the European Commission, funds were redirected and used aiming to overcome the consequences of the Covid-19 pandemic in the country. 

Bonus payments to front-line health care staff are included wich results in increase of the most of the spendings by HC and HP categories.

Expenditure on COVID-19 vaccines are not included (data not available). 

2021 - Included are the expenditure on the activities of the COVID-19 vaccines placement - different HP. Expenditure on COVID-19 vaccines are not included (data not available due to confidentiality).